CERTIFICATE OF LIABILITY INSURANCE (9) To: Chrystal From: Maria Crowell 3/4/2015 2:15:09 PM (Page 1 of 2)
• Allied Specialty Insurance
10451 Gulf Blvd
Treasure Island, FL 33706
To: C h rysta I
Company: City of Clearwater
Fax number: 1-727-562-4813
From: Maria Crowell
E-mail:
Company: Allied Specialty Insurance
Fax number: N/A
Business phone: 727-547-3042
Address: 10451 Gulf Blvd
Treasure Island, FIL 33706
Date &Time: 3/412015 2:15:13 PM
Pages: 2
Re: Certificate of Insurance for- Emerald Coast Bungee, Inc.
To: Chrystal From: Maria Crowell 314/2015 2:15:09 PM (Page 2 of 2)
AC40J? DATE 0&VDWYYYY)
111.� CERTIFICATE OF LIABILITY INSURANCE 3/04/15
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATHM ONLY AND CONFERS NO RJOITS UPON THE CERTIFICATE HOLDER.THIS
CIERTWICATE DOES Nor AFFIRMATIVELY OR NEGATTIOTLY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT SETVVEEN THE ISSUING INSUREP44), AUTHOFdZED
REPRESENTATIVE OR PRODUCE&AND THE CERTIFICATE HOLDER.
IMPORTANT. Of the terlffkate twiftr k M ADDITIONAL INSURED,the pol"(1les)nvist be endorsed, N SUBROGATION IS WAIVED, subject to
the tomm and conditions of the policy,certain policies rmy require an andorsament A xWoment an this cerfiftate does not confer rights to the
certireate holder In Neu of such endwswwridis),
POOMA"Allied S ecialty insurance, Inc
.10451 Guvf BIV
Treasure Islang, FL 33706
8002373355
IN,*m T.K.E. Tnsurance 12866
awf&D Emerald Coast Bun gee, Inc.
lie Causeway alvcl.17L 33767
C arwater Beach INPAWC:
COVERAGES CERTIFICATE NUMBER: REVIMN NUMBER,.
THIS 19 TO CERTIFY THAT THE POL)CIES OF INSURANCE LISTED BELOW HKVF BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY KFUOD
INDICATED, NOTINITHSTANDIN3 ANY REQILIIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCLNAENT NTH RESPECT To w4cH 7H*
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE NSLPANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS S1.6JECT"TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POUCIFS.LIMITS SHOWN MAY HAVE BEEN REDUCED MY PAID CLAIMS.
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A r COMMERCIALOMBALLIASILM CPP0100575-05 03111/15 06
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DEKMJRTKW OF OPERATIONSO LQCAT1QW1V0*CLe5 CAgWld4^0QRQ ICA,AAdftft Rme"Schedtft 9 PK"spe"is rWWw)
ADDITIONAL INSURED: CITY OF CLEARWATER AS RESPECT TO THE
PRM4ARY & NON-CONTRIBUTORY OPERATIONS OF THE NAKED INSURM ONLY.
WAIVER OF SUBROGATION APPLIES TO GENERAL LIABILITY.
RE: (1) FOUR STATION EURO HUNGEE #006
CERTIFICATE HOLDER CANCELLATION
TTY OF CLEARWATER SWMLD AW OF THE ABOVE DESCMBED POLICIES BECAAICELLED BEFORE
0 MYRTLE AVE NT THe EXPIKA-110IN DATE THE"OP, NOTICE WILL BE DeLAtERM IN
CLEARWATER Ft, 3767 ACCORDANCE VATH THE POUCY PROVOWNS.
A A ED REPR All
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Q 1988-201. CORD CORPORATION. All rights reserved.
ACORD 28(2010103) The ACORD name and logo are registered marks of ACORD